Electronic Theses and Dissertations

Date

2020

Document Type

Dissertation

Degree Name

Doctor of Philosophy

Department

Epidemiology

Committee Chair

Matthew Smeltzer

Committee Member

James Gurney

Committee Member

Kenneth Ward

Committee Member

Meredith Ray

Abstract

Lung cancer accounts for approximately 25% of all cancer deaths in the United States, and most long-term survivors of lung cancer undergo surgical resection. However, the effectiveness of surgical resection is impaired when tumor tissue remains at the margin of the resected specimen after the surgery, known as incomplete resection. The incidence of incomplete resection varies with patient demographic, clinical, surgeon, and institutional characteristics. The anatomic sites of margin involvement may also have impacts on long-term survival. Recommended postoperative treatment options for incomplete resection include re-resection, chemotherapy, and radiation therapy. However, some of these recommendations are not based on high-level evidence. A better understanding of the factors associated with margin positivity is needed to aid preoperative, intraoperative, and postoperative treatment decision making.The Mid-South Quality of Surgical Resection Cohort (MS-QSR) is a population-based dataset including > 95% of surgical resections of lung cancer in the Mid-South from 2009-2019. We evaluated the MS-QSR to disentangle the positive margins preoperative risk factors, the impact of postoperative treatments on positive margin, and survival outcomes.Among 3,414 patients evaluated in this study, 4.9% experienced incomplete resections. Risk factors associated with incomplete resection included male sex, unknown patients residency, advanced clinical stage (II and III), neo-adjuvant treatment, higher surgeon annual case volume, and urban location of hospital. Accurate TN (tumor and node) staging was a protective factor. Margin positivity was independently associated with an increase in the hazard of death (aHR=1.73, 95% CI: 1.40-2.13). Compared to complete resections, the anatomic sites significantly undermined the overall survival.We evaluated a hospital-based surgical quality metric called the risk-adjusted margin positivity (RAMP), which classified hospitals as underperformer, nonoutlier, or outperformer. In our analysis, the outperforming hospitals were more likely to attain quality criteria, had more surgeons with Cardiothoracic board certificate and predominant practice in thoracic or cardiovascular, and were more likely to be affiliated with a teaching program.Future work should focus on better identification of patients at risk for incomplete resection, improving the implementation of current guidelines and quality care at the institutional level, and generating higher level evidence to support postoperative treatment after incomplete resection.

Comments

Data is provided by the student.

Library Comment

Dissertation or thesis originally submitted to ProQuest

Notes

embargoed

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